Medical/Personal History Form

It is important to know details about your medical history as these could affect the success of your dental treatment and how we can provide this treatment. The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the at the base of this form.

PATIENT DETAILS

PATIENT CONTACT DETAILS

EMERGENCY CONTACT

GP's NAME & NUMBER

PRIVATE HEALTH INSURANCE

DVA Card

PLEASE TELL US


MEDICAL CONDITONS

You've answered "Yes" to the cancer question above. Can you please advise if cancer is past or present and what type of cancer.
You've answered "Yes" to the blood pressure question above. Can you please advise if your blood pressure is "high" or "low"
You've answered "Yes" to the hepatitis question above. Can you please advise what type of hepatitis you have had. Answer A, B or C.
You've ticked the "Other Conditions" box above. Please list this information below.

MEDICATIONS, ALLERGIES & CONCERNS

CONFIRM, AGREE TO OUR PRIVACY POLICY & SIGN

Clear